Name: Arthur Elklodge

Age: 57

Occupation: Carpenter

Case file: Admitted as an outpatient to Yellow Creek Treatment Center for complications with diabetes and alcoholism. Arthur has been seeing the Nutritionist for over two months with little improvement. His Hgba1c has increased from seven to nine over the past month and his blood lipids are accelerated. Although he denies drinking alcohol, the complications of his diabetes progressively worsen (to learn more about diabetes visit our website at http://www.montana.edu/wwwai/imsd/diabetes/)

Setting: (Arthur Elklodge walks into Goodie’s office, pulls up a chair, slouches one arm over the shoulder of his chair, and props the other on her desk as he rests his chin. As he crosses one leg over the other, he gazes outside the office window.)

Nutritionist TwoShoes: How you feeling today Arthur, you’re looking pretty relaxed. You’ve got some news for me this morning?

Arthur: Oh I’m doing jus’ fine. I’m sure looking forward to this evening. My son-in-law is taking us boating on the Tongue River Reservoir later. I guess it’s supposed to be in the 90’s by this afternoon.

Nutritionist TwoShoes: That sounds fun. (Getting directly to the point) So I see you’ve been drinking again lately.

Arthur: Now, who in the hell told on me this time!

Nutritionist TwoShoes: (Looking at the cuts on his fingers) Actually you told on yourself Arthur.

Arthur: Oh yeah, I hate those damn ‘ol beer cans. My fingers get too shaky tryin’ to open ‘em up. And those bottles are too ‘xpensive for me.

Nutritionist TwoShoes: You better go get that check so it doesn’t get infected.

Arthur: Now why should it get infected?

Nutritionist TwoShoes: Well you already know of the risk of infection due to your diabetes, but did you know that drinking also impairs your body’s ability to fight off infections?

Arthur: (chuckling) And what is your rationale there Goodie. I remember as a kid my father giving us a shot of liquor to fight off a cold. And even the syrups today aren’t nothing but alcohol and sugar!

Nutritionist TwoShoes: Well, Arthur, it is a known fact that alcoholics frequently suffer from infectious diseases and have increased rates of some cancers.

Arthur: And what does that have to do with infection?

Nutritionist TwoShoes: Well, it indicates that alcohol impairs the immune system, which protects the body against damage caused by infections by microorganisms, damage caused by other foreign substances, and the uncontrolled, tumorous growth of the body’s own cells. Clinicians have known for a long time that chronic alcohol abusers have an impaired immune system. Interestingly, not only chronic alcohol abuse but also single episode (i.e., acute) and/or moderate alcohol consumption can affect the immune system.

Arthur: (thinking) Hmmm, that is interesting, Goodie.

Nutritionist TwoShoes: Now, I hope you’re watching how much you drink, and you’re not overdoing it, Art.

Arthur: Well, what about all this beneficial crap that alcohol has on my heart?!

Nutritionist TwoShoes: Now Arthur, remember what I told you before. There is evidence that MODERATE alcohol consumption does have beneficial effects in decreasing the risk of death due to coronary heart disease in people with older-onset diabetes, but remember this recommendation is only for people who don’t have drinking problems.

Arthur: (Denying her comments) Nah, I heard that off the news the other day.

Nutritionist TwoShoes: (Smiling) I’m glad to know that you watch the news Arthur.

Arthur: (Proudly) Oh I turn on the tube every once in a while there, Goodie.

Nutritionist TwoShoes: I want you to be careful though, Arthur, because sometimes the media claims more than what is really out there.

Arthur: What are ya tryin’ to tell me, that those there news people are just a bunch of liars? (Looking outside the window at the intensifying growth of thunder clouds in the distance) Well I sure know those goddamn weathermen are.

Nutritionist TwoShoes: What the media isn’t telling you is the rest of the story . . .

Arthur: (Interrupting) Now who in the hell you trying to be, Paul Harvey?! (Mumbling) and this is the rest of the story. . .

Nutritionist TwoShoes: (Appreciating his humor) You always have something to say, don’t you, Arthur. Well, what do you have to say about moderation?

Arthur: (Cynical) Hmm, a couple of cases of beer or a pint of whiskey.

Nutritionist TwoShoes: (Slightly humored) Now I know you know that is NOT what it means.

Arthur: All right. It means reasonable, like a can of beer or a shot of whiskey.

Nutritionist TwoShoes: That’s better. The American Diabetic Association recommends no more than two drinks per day for men and no more than one drink per day for women. And remember what a drink is equal to (showing him a diagram).

1 drink = 1 beer

1 drink = 4 ounces of wine

1 drink = 1.5 ounces or a “shot” of liquor

Arthur: (Shaking his head with disgust) Not a whole keg, eh. Not even a case.

Nutritionist TwoShoes: And if you so desire to have the whole case, you should be aware of the dangers you are placing yourself at. Not only are you complicating your diabetic therapy, you are also increasing your risk for adverse cardiovascular effects, increasing your risk for hypoglycemia, inducing temporary hyperglycemia, and predisposing yourself to alcoholic ketoacidosis.

Arthur: Oh Goodie, if I’ve lived to be this old havin’ a bottle here and there, I should be fine continuin’ in my ways.

Nutritionist TwoShoes: You’ve never had diabetes your entire life either now, have you, Arthur?

Arthur: Alcohol has never hurt me before, why should it hurt me now?

Nutritionist TwoShoes: Actually, Arthur, there is evidence that alcohol intake is associated with increased insulin sensitivity in young adult life as well as alcohol consumption associated with an increased risk of developing type II diabetes. So, you might actually be paying for all those party days you’ve had during your younger days.

Arthur: (Taken back) Huh. I never knew. . . (Concluding) Ah hell, I’m okay.

Nutritionist TwoShoes: There’s even evidence among the Apache Indians that ketoacidosis, a complication that is more commonly associated with insulin-dependent diabetes mellitus, can occur in some patients with non-insulin-dependent mellitus because of alcohol abuse in their life.

Arthur: Well, I’m not Apache, now am I Miss Goodie TwoShoes?! I am a full-blooded, reservation raised Northern Chey-enne.

Nutritionist TwoShoes: There’s even more research looking at blood quantum, diabetes, and alcoholism. Did you know there is a relationship between amount of Indian blood and risk of developing diabetes and alcoholism?

Arthur: (Disturbed) Damn it, woman! First it was the BIA trying to separate our people by blood, now it’s the health care providers. Whose side you on anyway?

Nutritionist TwoShoes: There’s no time to be playing Russian roulette when it comes to your health, Arthur. I’m not taking sides, or playing any games here. I am only trying to inform you of your situation and let you face the facts. (Gravely) If you don’t stop your drinking, it is going to do more damage than we can help here.

Arthur: (Taking a deep breath and staring out the window) “Damn ‘ol weathermen anyway.” (He mumbles to himself.)

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Setting: Earlier that week Arthur’s wife, Amanda, came in to talk to Goodie about her husband’s situation. She mentions his recent disinterest in sexual activities and wonders if there is any connection to his health complications.

Amanda: I don’t know what it is. At first I thought it was my sexual appeal, so I went to the corner store and bought me some new bloomers (smiling with pleasure). After that didn’t work, I thought it was my cooking. So, I had my sister teach me her secrets to making some frybread. . . she’s the frybread queen around here ya know (nodding at Goodie). Now, I am almost to my last resort . . .

Nutritionist TwoShoes: (Grinning) Plan C, huh.

Amanda: I was wondering if you had any secret recipes to increase a man’s sexual drive. You know, whatever those Crow women feed to their men over there . . .

Nutritionist TwoShoes: (Leaning forward with interest) Oh yeah?

Amanda: I’ve heard they can go all night long, even when they’re in their 60’s!

Nutritionist TwoShoes: (Laughing) Actually, Amanda, I don’t know what foods, or if there really are any, that can increase a man’s sexual drive. Believe me, honey, or else I’d have my whole field planted with whatever it is instead of that there golden wheat.

Amanda: (Embarrassed) Well, do you have ANY kind of nutritional advice to help our situation?

Nutritionist TwoShoes: Yes, in fact, I do. We both know your husband has a drinking problem that is creating complications with his diabetes.

Amanda: (Eagerly) Yes.

Nutritionist TwoShoes: Well, it obviously is creating complications with his personal life as well.

Amanda: (Shaking her head) I can testify on that!

Nutritionist TwoShoes: There is evidence that male erectile dysfunction, known as impotence, is caused by both Alcoholism and Diabetes. Of course there are other risk factors for being diagnosed as impotent such as family history, hypertension, smoking, and hyperlipideaemia. But your husband has two risk factors and the more you have, the more likely you will suffer from this problem

Amanda: Actually, he has three of the risk factors you identified Goodie. He also has high lipid levels in his blood. I have been cooking low- fat meals for him to improve his condition.

Nutritionist TwoShoes: Oh that’s right, isn’t it. His high lipid level is a very critical component of his health status. Although the ADA guidelines allow that people with well-controlled diabetes can indulge in a drink or two with meals, not everyone with diabetes can or should. Alcohol is a carbohydrate that’s metabolized in the body as a fat. So a bottle of beer or a glass of wine counts as two fat exchanges (10 grams of fat, or 90 calories). Therefore, as you can see, alcohol can drive up tryglycerides, and if consumed without food can cause blood-sugar levels to drop. This creates even more dangerous situations, such as hypoglycemia. Are you comfortable with this area?

Amanda: Arthur is actually pretty good about watching his blood sugar levels, so hypoglycemia hasn’t been a problem. . . yet. Well, this is what he tells me anyway. And I watch his fat intake pretty closely, it’s just that darn ‘ol alcohol of his I can’t control.

Nutritionist TwoShoes: That’s good that you are trying to reduce the amount of fat in his diet, Amanda. Arthur is sure lucky to have such a supportive wife as you.

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Setting: Back in Goodie’s office with Arthur.

(Reflecting on her conversation with Arthur’s physician he regularly sees at the Indian Health Service, Goodie remembers a pivotal conversation regarding Arthur’s diabetes and alcohol problem.)

Physician: So, it’s Arthur you’re concerned about?

Nutritionist TwoShoes: Yes. I have tried every direction to motivate him to quit his drinking. He just doesn’t seem to listen to the warning signs he is receiving about his health.

Physician: Well, there is one highly sensitive diagnostic tool for uncovering his drinking problem . . . called conversation. Talking to Arthur about his alcoholism may be the only way to uncover a hidden problem.

Nutritionist TwoShoes: Hidden problem? I’ve discussed every complication he is experiencing as a result of his diabetes and alcoholism.

Physician: There’s more to the story that will hit home for him. It’s called penile erection dysfunction. Since the majority of men aren’t willing to ask about it, especially Indian men, it may be up to you to start the conversation Goodie.

Nutritionist TwoShoes: Me, but how?

Physician: Ask him how things are going at home.

Nutritionist TwoShoes: Wouldn’t that be prying into his personal life?

Physician: Exactly. Allow him to make that connection you just did and see what kind of changes he is willing to sacrifice in order to save his personal gratification.

Nutritionist TwoShoes: Ahhh, clever Dr., very clever.

Physician: Maybe his drinking is due to stress, addiction, or embarrassment. But penile erection dysfunction is due to both diabetes and alcoholism.

Nutritionist TwoShoes: That’s right.

Physician: Whatever the underlying cause for his drinking problem, any conversation about improving his health, especially his personal well being, is a conversation worth having. Remember, with just a moment of your time you could make a world of difference in your patients (winking at Goodie).

Nutritionist TwoShoes: Thanks Doc.

Goodie flashes back into reality and sees Arthur scanning the ceiling, as if it were more exciting to indulge with than the conversation at hand.

Click here if Goodie talks with Arthur about his diabetic complications

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